GC | Overview

Overview | Glycemic Control Implementation Toolkit

This Glycemic Control Implementation Toolkit is part of a continuing effort over the last decade by the Society of Hospital Medicine (SHM) to provide accurate guidance on best practices in glycemic control in the inpatient setting. This comprehensive Toolkit focuses not only on what should be done but also on how to do it. This is the fourth major revision of the Glycemic Control Online Toolkit, further illustrating SHM’s dedication to meeting the needs of its members, continuous improvement and addressing major issues occurring in hospitals around the world.

The goal of this Toolkit is to provide users with concise guidance and tips to help them assess the current state of their glycemic control care, gain institutional support, build an effective team, choose metrics to follow, implement proven interventions and continue to assess and improve over time. We have chosen to focus this edition less on the research and justification for these measures, though we will refer users to these resources, and instead to spend our time on clear, actionable guidance to help teams that are champions in their institutions to improve patient care regarding the prevention of hypoglycemia and appropriately preventing and treating hyperglycemia.

Glycemic Mentoring Program Information Download the Glycemic Control Implementation Guide

We recognize that there are knowledge gaps about evidence surrounding some of these recommendations, and that research and guidelines are still evolving in this area. However, incomplete or imperfect evidence is not an excuse for inaction or unacceptable standards that have been shown to be ineffective and at times potentially dangerous to patients. Thus, we will make recommendations based on the best evidence available, making every effort to make this information clear. Please keep in mind from the outset that achieving safe and effective glycemic control for inpatients requires a multidisciplinary approach. From the team composition to the design and implementation of interventions, all levels of the hospital and staff must be actively involved. We must also remember that our goals do not end on discharge. In addition to preventing uncontrolled hyperglycemia and not causing hypoglycemia, we must also ensure safe and effective transitions into and out of the hospital and provide adequate education to set patients on the right path to controlling their disease for a lifetime.

Throughout this Toolkit you will achieve the following essential elements to reach breakthrough levels of improvement in the care of patients with hyper- and hypoglycemia:

  • Gain institutional support for and prioritization of this initiative, expressed as a meaningful investment in time, equipment, informatics and personnel in the effort
  • Create a multidisciplinary team or Steering Committee that is focused on reaching glycemic targets and on many other aspects of the care of the inpatient with hyperglycemia and/or diabetes and that regularly reports to key medical staff committees
  • Develop specific aims, or goals, that are time defined, measurable and achievable
  • Assess the current state of glycemic management in your facility through an in-depth self-assessment utilizing tools such as process mapping
  • Review and identify best practices for the management of diabetes and hyperglycemia for patients in your hospital
  • Choose reliable metrics and collect data that, at a minimum, reflect glycemic control, hypoglycemia frequency and insulin use patterns. These data should be transformed into reports that inform the team and frontline workers of progress and problem areas to address
  • Deploy interventions and monitor impacts to decrease hyperglycemia by drafting and approving algorithms, policies and protocols to ensure effective processes that are institution-specific and that support the order sets and promote their safest and most effective use. These tools must not merely exist; they must be widely disseminated and used and, in some cases, be embedded in CPOE order sets. A high-reliability design should be used to enhance effective implementation. These interventions include:
  1. Understanding the principles of effective implementation and high-reliability design
  2. Building effective and high-performing inpatient diabetes management teams
  3. Designing and implementing subcutaneous insulin order sets that promote the rational and evidence-based application of insulin in critical care and non-critical care settings
  4. Designing and implementing an insulin infusion order set
  5. Designing and implementing a DKA protocol
  6. Designing and implementing perioperative protocols and order sets
  7. Improving transitions of care for patients with hyperglycemia into the hospital, off insulin infusion and from the hospital to home
  8. Administering comprehensive education and certification programs for healthcare providers and patients, reinforcing both general and institution-specific information, including education about the items listed under algorithms, policies and protocols
  • Developing processes and structures to prevent hypoglycemia through safe insulin management practices and a hypoglycemia reduction bundle; and improving processes around nutrition, insulin administration including consideration of use of insulin pens and policies around subcutaneous insulin pumps
  • Change and maintain a new culture of improvement that will allow the institution to maintain gains made and to continue to improve over time

Glycemic Control Project Team

The first edition of this Toolkit was supported in part by a non-educational grant from sanofi-aventis US, LLC.
The second edition of this Toolkit is supported in part by an educational grant from Novo Nordisk in 2015.

Disclaimer
The Glycemic Control Implementation Toolkit is an online resource for visitors to the Society of Hospital Medicine's (SHM’s) website. All content and links have been reviewed by the Glycemic Control Implementation Toolkit Project Team; however, the Society of Hospital Medicine does not exercise any editorial control over content associated with the external links that have been made available via this website.